Considerations to Optimize Structurally Responsive Work Environments for U.S. Military Specialty Physicians.

INTRODUCTION: Recruitment, training, and retention of wartime critical specialty physicians may be stymied by discrimination and abuse. It is unclear to what extent the US combat specialty physicians witness or experience discrimination and abuse, whether they or others intervene, and if they would subsequently discourage people from entering their field. MATERIALS AND METHODS: The present study surveyed US active duty anesthesiologists, emergency medicine physicians, and orthopedic surgeons (N = 243; 21% response rate). A generalized linear model evaluated the extent to which gender, specialty, service, and number of witnessed/experienced negative/stigmatizing comment/event types were associated with burnout. A bootstrapped mediation analysis evaluated whether gender and burnout were mediated by the number of comment/event types. RESULTS: The sample was majority non-Latine White (87%) and men (66%) with tri-service and specialty representation. The most commonly reported negative/stigmatizing comment/event types were related to pregnancy (62%) and parental leave (61%), followed by gender and assigned sex (42%), lactation (37%), and sexual harassment (35%). Of the respondents who witnessed/experienced such comments/events, self-intervention was reported after comments regarding lactation (43%), assigned sex and gender (42%), race and ethnicity (41%), pregnancy (41%), parental leave (37%), and sexual harassment (24%). Witnessing another person intervene was reported after sexual harassment (25%) and comments/events regarding race and ethnicity (24%), pregnancy (20%), assigned sex and gender (19%), lactation (19%), and parental leave (18%). Nonintervention was reported after comments/events related to parental leave (42%), pregnancy (38%), sexual harassment (26%), lactation (26%), assigned sex and gender (26%), and race and ethnicity (22%). Respondents reported moderate-to-high intervening likelihood, importance, and confidence. Respondents reporting neutral to extremely agree on prompts indicating that pregnant active duty physicians are trying to avoid deployment (P = .002) and expect special treatment that burdens the department (P = .007) were disproportionately men (36% and 38%, respectively) compared to women (14% and 18%, respectively). The highest proportion of neutral to extremely agree responses regarding discouraging specialty selection were reported in relation to transgender and gender diverse students (21%), followed by cisgender female students (18%); gay, lesbian, or bisexual+ students (17%); cisgender male students (13%); and racial and ethnic minoritized students (12%). In the primary model, the number of witnessed/experienced comment/event types was associated with greater burnout (0.13, 95% CI 0.06-0.20, P = .001), but women did not report significantly different levels of burnout than men (0.20, 95% CI -0.10 to 0.51, P = 0.20). The number of comment/event types mediated the relationship between gender and burnout (0.18, 95% CI 0.06, 0.34; P < .001). CONCLUSIONS: Although reported intervening confidence, likelihood, and importance were high, it is unclear whether perceptions correspond to awareness of intervention need and behaviors. Bivariate differences in burnout levels between men and women were fully explained by the number of comment types in the mediation model. Annual trainings may not effectively address workplace climate optimization; institutions should consider targeted policy and programmatic efforts to ensure effective, structurally responsive approaches.

Analyzing unmanned aerial vehicle (drone) attacks; a disaster medicine perspective.

INTRODUCTION: Unmanned aerial vehicles (UAVs), more commonly known as drones, have rapidly become more diverse in capabilities and utilization through technology advancements and affordability. While drones have had significant positive impact on healthcare and consumer delivery particularly in remote and austere environments, Violent Non-State Actors (VNSAs) have increasingly used drones as weapons in planning and executing terrorist attacks resulting in significant morbidity and mortality. We aim to analyze drone-related attacks globally against civilians and critical infrastructure for more effective hospital and prehospital care preparedness. METHODS: We retrospectively reviewed the Global Terrorism Database (GTD) from 1970 to 2020 to analyze the worldwide prevalence of drone-related attacks against civilians and critical infrastructure. Cases were excluded if they had insufficient information regarding a drone involvement, and if attacks were conducted by the government entities. The trends in the number of attacks per month, as well as the number of fatalities and injuries, were examined using time series and trend analysis. RESULTS: The database search yielded 253 drone-related incidents, 173 of which met inclusion criteria. These incidents resulted in 92 fatalities and 215 injuries with civilian targets most commonly attacked by drones (76 events, 43.9%), followed by military (46 events, 26.5-%). The Middle East region was most affected (168 events, 97% of attacks) and the Islamic state of Iraq was the most common perpetrator (106 events, 61.2%). Almost all attacks were by explosive devices attached to drones (172 events, 99.4%). Time series with linear trend analyses suggested an upward trends of drone attacks by VNSAs, resulting in a greater number of injuries and fatalities, that became more frequent over the years. CONCLUSIONS: Overtime, there were upward trends of drone attacks, with higher lethality and morbidity. There were more injuries compared to fatalities. Most common region affected was the Middle East, and most common type of weapon employed by drone technology was explosive weapon. Investment in medical personnel training, security, and research is crucial for an effective mass-casualty incident response after the drone attacks.

A Comparison of Uniformed Services University and Health Professions Scholarship Program Graduates' First Deployment Readiness.

INTRODUCTION: Military physicians must be prepared to lead health care teams across complex landscapes of war during future small- and large-scale combat operations. This preparation optimally begins in medical school so that early career physicians are fully ready for their first deployment. Past qualitative research has suggested that military physicians who attended civilian medical school are not as well prepared for the operational environment as physicians who attended the Uniformed Services University (USU), our nation's military medical school. However, there is a lack of larger-scale quantitative research comparing the readiness differences between the two medical school pathways. The purpose of this study, therefore, was to quantify any differences in first deployment preparation between students attending USU and civilian medical schools through the Health Professions Scholarship Program (HPSP). MATERIALS AND METHODS: We compared USU and HPSP graduates' first deployment experiences by distributing a 14-item Likert survey to active duty military physicians in the U.S. Army, U.S. Navy, and U.S. Air Force who graduated within the past 10 years from medical school (USU or civilian). RESULTS: The USU graduates rated themselves significantly higher than the HPSP graduates on their readiness for deployment (3.83 vs. 3.24; P < .001); ability to navigate the operational environment (3.59 vs. 2.99; P < .001); confidence in communicating with their commanding officer (3.59 vs. 2.99; P = .002); navigating the combined role as physician and officer (3.33 vs. 2.84; P = .004); leading a health care team (3.94 vs. 3.43; P = .001); preparation by a medical school (3.78 vs. 2.52; P < .001); and overall readiness compared to peers (4.20 vs. 3.49; P < .001). There was no significant difference between the two pathways regarding their stress level at the beginning of deployment (2.74 vs. 2.68; P = .683); clinical preparation (3.94 vs. 3.76; P = .202); and success of first deployment (3.87 vs. 3.91; P = .792). The largest effect size of the difference between the two pathways was noted on the question "How well did medical school prepare you for your first deployment" (Cohen's d = 1.02). CONCLUSIONS: While both groups believed that they were prepared for their first deployment, USU graduates consistently reported being more prepared by medical school for their first deployment than HPSP graduates. To close this readiness gap, supplemental military unique curricula may help to optimize HPSP students' readiness.

Racialized and beneficiary inequities in medication to treat opioid use disorder receipt within the US Military Health System.

BACKGROUND: Medication for opioid use disorder (MOUD) can be critical to managing opioid use disorder (OUD). It is unknown the extent to which US Military Health System (MHS) patients diagnosed with OUD receive MOUD. METHODS: Healthcare records of MHS-enrolled active duty and retired service members (N = 13,334) with a new (index) OUD diagnosis were included between 2018 and 2021, without 90-day pre-index MOUD receipt were included. Elastic net logistic and Cox regressions evaluated care- and system-level factors associated with 1-year MOUD receipt (primary outcome) and time-to-receipt. RESULTS: Only 9% of patients received MOUD 1-year post-index; only 4% received MOUD within 14 days. Black patients (OR for receipt 0.38, 95% CI 0.30-0.49), Latinx patients (OR for receipt 0.44, 95% CI 0.33-0.59), and patients whose race and ethnicity was Other (OR for receipt 0.52, 95%CI 0.35, 0.77) experienced lower MOUD access (all p < 0.001). Retirees were more likely to receive MOUD relative to active duty service members (OR for receipt 1.81, 95%CI 1.52, 2.16, p <0.001). CONCLUSIONS: Institutional racism in MOUD prescribing, combined with the overall low rates of MOUD receipt after OUD diagnosis, highlight the need for evidence-based, multifaceted, and multilevel approaches to OUD care in the Military Health System. Without clear Defense Health Agency policy, including the designation of responsible entities, transparent and ongoing evaluation and responsiveness using standardized methodology, and resourced programming and public health campaigns, MOUD rates will likely remain poor and inequitable.

Prior Enlisted Medical Students at the Uniformed Services University: Outcomes During Four Years of Medical School.

INTRODUCTION: The Uniformed Services University (USU) implemented the Enlisted to Medical Degree Preparatory Program (EMDP2) with the goal of enhancing the diversity of the military physician corps. Programs like EMDP2 can assist students in making the social and intellectual transition from undergraduate studies to medical school and beyond. These types of programs are also opportunities to reduce health disparities and prepare students to work in multicultural settings. The purpose of this study was to evaluate whether there was any significant difference in performance between USU medical students who had attended the EMDP2 and those who had not. MATERIALS AND METHODS: We compared the results of National Board of Medical Examiners (NBME) Clinical Science Subjects, United States Medical Licensing Examination (USMLE) Step 1, and USMLE Step 2 Clinical Knowledge exams of EMDP2 learners from the School of Medicine classes of 2020 to 2023 to those of four similarly sized cohorts of their peers who varied by age and prior military service. RESULTS: We found that the performance of EMDP2 graduates was comparable to their peers who followed more traditional and other alternative paths to medical school. For example, regression models showed that EMDP2 status was not a statistically significant predictor of average clerkship NBME exam score, nor of USMLE Step 1 failure. CONCLUSION: EMDP2 graduates performed on a par with their medical school peers, and EMDP2 status does not appear to influence NBME or USMLE performance. EMDP2 provides a focused curriculum and addresses the mandate to make medical education opportunities available to a more diverse population.

The Impact of Operation Bushmaster on Medical Student Decision-making in a High-Stress, Operational Environment.

INTRODUCTION: Operation Bushmaster is a high-fidelity military medical field practicum for fourth-year medical students at the Uniformed Services University. During Operation Bushmaster, students treat live-actor and mannequin-based simulated patients in wartime scenarios throughout the five-day practicum. This study explored the impact of participating in Operation Bushmaster on students' decision-making in a high-stress, operational environment, a crucial aspect of their future role as military medical officers. MATERIALS AND METHODS: A panel of emergency medicine physician experts used a modified Delphi technique to develop a rubric to evaluate the participants' decision-making abilities under stress. The participants' decision-making was assessed before and after participating in either Operation Bushmaster (control group) or completing asynchronous coursework (experimental group). A paired-samples t-test was conducted to detect any differences between the means of the participants' pre- and posttest scores. This study was approved by the Institutional Review Board at Uniformed Services University #21-13079. RESULTS: A significant difference was detected in the pre- and posttest scores of students who attended Operation Bushmaster (P < .001), while there was no significant difference in the pre- and posttest scores of students who completed online, asynchronous coursework (P = .554). CONCLUSION: Participating in Operation Bushmaster significantly improved the control group participants' medical decision-making under stress. The results of this study confirm the effectiveness of high-fidelity simulation-based education for teaching decision-making skills to military medical students.

Medical Students' Integration of Formative Feedback During Simulation: A Grounded Theory Study.

INTRODUCTION: Formative feedback is critical for trainees' growth and development. However, there is a gap in the professional literature regarding the ways in which formative feedback affects student performance during simulation. This grounded theory study addresses this gap by exploring the ways in which medical students received and integrated ongoing formative feedback throughout a multiday, high-fidelity military medical simulation, Operation Bushmaster. MATERIALS AND METHODS: Our research team interviewed 18 fourth-year medical students in order to investigate how they processed formative feedback during the simulation. Guided by the grounded theory tradition of qualitative research, our research team used open coding and axial coding to categorize the data. We then used selective coding to determine the casual relationships between each of the categories that emerged from the data. These relationships determined our grounded theory framework. RESULTS: Four phases emerged from the data and provided a framework to delineate the process in which students received and integrated formative feedback throughout the simulation: (1) ability to self-assess, (2) self-efficacy, (3) leadership and teamwork, and (4) appreciation of feedback for personal and professional growth. The participants first focused on feedback related to their individual performance but then shifted to a teamwork and leadership mindset. Once they adapted this new mindset, they began to intentionally provide feedback to their peers, increasing their team's performance. At the end of the simulation, the participants recognized the benefits of formative feedback and peer feedback for ongoing professional development throughout their careers, signifying a growth mindset. CONCLUSIONS: This grounded theory study provided a framework for determining how medical students integrated formative feedback during a high-fidelity, multiday medical simulation. Medical educators can use this framework to intentionally guide their formative feedback in order to maximize student learning during simulation.

The Impact of Special Operations Medics and Corpsmen on Military Medical Student Training: A Qualitative Study.

Operation Gunpowder is a high-fidelity military medical field practicum conducted by the Uniformed Services University of Health Sciences, Bethesda, MD. During this multi-day combat simulation, Special Operations Medics and Corpsmen teach military medical students how to treat patients in an austere, resource-limited environment. To investigate the effectiveness of this teaching model, our research team used a qualitative phenomenological design to explore medical students' experiences being taught by Special Operations Medics and Corpsmen during Operation Gunpowder. We found two themes regarding the medical students' personal and professional development: an increased understanding of medics' skills and capabilities and the realization of their future roles as educators and leaders. Our study suggests that the use of Special Operations Corpsmen and Medics in medical student training is a valuable model for both military and civilian medical education and training.

Military Medical Provider Perspectives During the New York COVID-19 Response.

INTRODUCTION: The response to the coronavirus disease 2019 pandemic in New York City (NYC) included unprecedented support from the DoD-a response limited primarily to medical and public health response on domestic soil with intact infrastructure. This study seeks to identify the common perspectives, experiences, and challenges of DoD personnel participating in this historic response. MATERIALS AND METHODS: This is a phenomenological qualitative study of 16 military health care providers who deployed to NYC in March 2020. This study was approved by the Institutional Review Board at the USU (No. DBS.2020.123). All participants served on either the United States Naval Ship Comfort or at the Javits Center. We conducted semi-structured interviews exploring the participants' experiences while deployed to NYC. These interview scripts were then independently coded by five research team members. RESULTS: We identified four common themes and 12 subthemes from the participants' responses. The themes (subthemes) were lack of preparation (unfamiliar mission and inadequate resources); confusion about integration with civilian health care (widespread, dynamic situation, and NYC overwhelmed), communication challenges (overall, misunderstanding and miscommunication resulting in tension, and patient handoffs); and adaptation and success (general, military-civilian liaison service, positive experience, and military support necessity). CONCLUSIONS: This study provides unique insight into the DoD's initial response to the coronavirus disease 2019 pandemic in NYC. Using this experiential feedback from the DoD's pandemic responders could aid planners in improving the rapidity, effectiveness, and safety of military and civilian health care system integrations that may arise in the future.

Medical Students' Professional Identity Formation During Operation Bushmaster.

INTRODUCTION: The role of the military medical officer is complex, as it encapsulates officer, physician, and leader. Professional identity formation is therefore essential for military medical students and junior military physicians to successfully execute the responsibilities of the military medical officer in their future careers. Because little is known regarding best practices for professional identity formation training for military physicians, this study explored the ways in which medical students conceptualized the complex roles of the military medical officer during a medical field practicum. MATERIALS AND METHODS: Guided by the phenomenological tradition of qualitative research, we interviewed 15 fourth-year medical students twice regarding their understanding of the role of the military medical officer, as they progressed through a 5-day high-fidelity military medical field practicum, Operation Bushmaster. Our research team then analyzed the interview transcripts for emerging themes and patterns, which served as the results of this study. RESULTS: The following themes emerged from the data regarding the participants' conceptualization of the military medical officer: (1) the scope of the role of the military medical officer; (2) the intersecting identities of the military medical officer; and (3) the adaptable role of the military medical officer in an operational environment. As they progressed through the medical field practicum, the participants articulated a clear understanding of the vast and complex nature of the military medical officer's intersecting roles as officer, physician, and leader in austere and often unpredictable environments. At the end of the medical field practicum, the participants expressed confidence in carrying out their roles as military medical officers during their future deployments. CONCLUSIONS: This study provided an in-depth understanding of the participants' conceptualization of the military medical officer. The participants described how the medical field practicum provided them with opportunities to experience first-hand and therefore better understand the roles of the military medical officer while leading a health care team in an operational environment. As a result, high-fidelity medical field practicums like Operation Bushmaster appear to be an effective tool for facilitating professional identity formation.

Airway and Hypothermia Prevention: and Treatment via STEAM The System for Thermogenic Emergency Airway Management.

Military medicine has made significant advancements in decreasing mortality by addressing the lethal triad - metabolic acidosis, coagulopathy, and hypothermia. However, casualties are still succumbing to injury. Recent conflict zones have led to the development of remarkable life-saving innovations, including the management of compressible hemorrhage and whole blood transfusions. Nevertheless, hypothermia prevention and treatment techniques remain relatively unchanged. Hypothermia prevention is anticipated to become more critical in future operations due to a predicted increase in evacuation times and reliance on Prolonged Casualty Care (PCC). This is likely secondary to increasingly distanced battlespaces and the mobility challenges of operating in semi-/non-permissive environments. Innovation is essential to combat this threat via active airway rewarming in the vulnerable patient. Thus, we propose the development, fabrication, and efficacy testing of a device in which we estimate being able to control temperature and humidity at physiologic levels in the PCC setting and beyond.

Military Response to Medical Crises-Consensus Recommendations for Military-Civilian Transitions of Care.

OBJECTIVE: The threat that New York faced in 2020, as the COVID-19 pandemic unfolded, prompted an unprecedented response. The US military deployed active-duty medical professionals and equipment to NYC in a first of its kind response to a "medical" domestic disaster. Transitions of care for patients surfaced as a key challenge. Uniformed Services University and the Icahn School of Medicine at Mount Sinai hosted a consensus conference of civilian and military healthcare professionals to identify care transition best practices for future military-civilian responses. METHODS: We performed individual interviews followed by a modified Delphi technique during a two-day virtual conference. Patient transitions of care emerged as a key theme from pre-conference interviews. Twelve participants attended the two-day virtual conference and generated best practice recommendations from an iterative process. RESULTS: Participants identified 19 recommendations in 10 "sub-themes" related to patient transitions of care: needs assessment and capability analysis; unified command; equipment; patient handoffs; role of in-person facilitation; dynamic updates; patient selection; patient tracking; daily operations; and resource typing. CONCLUSIONS: The COVID-19 pandemic resulted in an unprecedented military response. This study created 19 consensus recommendations for care transitions between military and civilian healthcare assets that may be useful in future military-civilian medical engagements.

Naloxone Prescribing Associated With Reduced Emergency Department Visits in the Military Health System.

PURPOSE: The aim was to determine the association between the receipt of naloxone and emergency department (ED) visits within 60 days after the receipt of an opioid. METHODS: A retrospective cohort of individuals 18 years of age or above, enrolled in TRICARE, and were dispensed an opioid at any time from January 1, 2019, through September 30, 2020 was identified within the United States Military Health System. Individuals receiving naloxone within 5 days of the opioid dispensing date were propensity score matched with individuals receiving opioids only. A logistic regression was used to estimate the odds of an ED visit in the 60-day follow-up period after the index opioid dispense event among those co-dispensed naloxone and those receiving opioids only. RESULTS: Of the 2,136,717 individuals who received an opioid prescription during the study period, 800,071 (10.1%) met study inclusion criteria. Overall, 5096 (0.24%) of individuals who received an opioid prescription were co-dispensed naloxone. Following propensity score matching, those who received naloxone had a significantly lower odds of ED utilization in the 60 days after receiving an opioid prescription (odds ratio: 0.74, 95% CI: 0.68-0.80, P<0.001). CONCLUSION: This study highlights the importance of expanding access to naloxone in order to reduce ED utilization. Future research is needed to examine additional outcomes related to naloxone receipt and develop programs that make naloxone prescribing a routine practice.

Naloxone prescribing practices in the Military Health System before and after policy implementation.

Introduction: Despite public health campaigns, policies, and educational programs, naloxone prescription rates among people receiving opioids remains low. In June 2018, the U.S. Military Health System (MHS) released 2 policies to improve naloxone prescribing. Objectives: The objective of this study was to examine whether the policies resulted in increased naloxone coprescription rates for patients who met the criteria for 1 or more risk indicators (eg, long-term opioid therapy, benzodiazepine coprescription, morphine equivalent daily dose ≥50 mg, and elevated overdose risk score) at the time of opioid dispense. Methods: Prescription and risk indicator data from January 2017 to February 2021 were extracted from the MHS Data Repository. Naloxone coprescription rates from January 2017 to September 2018 were used to forecast prescribing rates from October 2018 to February 2021 overall and across risk indicators. Forecasted rates were compared with actual rates using Bayesian time series analyses. Results: The probability of receiving a naloxone coprescription was higher for patients whose opioid prescriber and pharmacy were both within military treatment facilities vs both within the purchased-care network. Bayesian time series results indicated that the number of patients who met the criteria for any risk indicator decreased throughout the study period. Naloxone prescribing rates increased across the study period from <1% to 20% and did not significantly differ from the forecasted rates across any and each risk indicator (adjusted P values all >0.05). Conclusion: Future analyses are needed to better understand naloxone prescribing practices and the impact of improvements to electronic health records, decision support tools, and policies.

Super-Utilization of the Emergency Department in a Universally Insured Population.

INTRODUCTION: Super-utilizers (patients with 4 or more emergency department [ED] visits a year) account for 10% to 26% of all ED visits and are responsible for a growing proportion of healthcare expenditures. Patients recognize the ED as a reliable provider of acute care, as well as a timely resource for diagnosis and treatment. The value of ED care is indisputable in critical and emergent conditions, but in the case of non-urgent conditions, ED utilization may represent an inefficiency in the healthcare system. We sought to identify patient and clinical characteristics associated with ED super-utilization in a universally insured population. MATERIAL AND METHODS: We performed a retrospective cohort study using TRICARE claims data from the Military Health System Data Repository (2011-2015). We reviewed the claims data of all adult patients (aged 18-64 years) who had at least one encounter at the ED for any cause. Multivariable logistic regression was used to determine independent factors associated with ED super-utilization. RESULTS: Factors associated with increased odds of ED super-utilization included Charlson Score ≥2 (adjusted odds ratio [aOR] 1.98, 95% confidence interval [CI]: 1.90-2.06), being eligible for Medicare (aOR 1.95, 95% CI: 1.90-2.01), and female sex (aOR 1.35, 95% CI: 1.33-1.37). Active duty service members (aOR 0.69, 95% CI 0.68-0.72) and beneficiaries with higher sponsor-rank (Officers: aOR 0.50, 95% CI: 0.55-0.57; Senior enlisted: aOR 0.82, 95% CI: 0.81-0.83) had lower odds of ED super-utilization. The most common primary diagnoses for ED visits among super-utilizers were abdominal pain, headache and migraine, chest pain, urinary tract infection, nausea and vomiting, and low back pain. CONCLUSIONS: Risk of ED super-utilization appears to increase with age and diminished health status. Patient demographic and clinical characteristics of ED super-utilization identified in this study can be used to formulate healthcare policies addressing gaps in primary care in diagnoses associated with ED super-utilization and develop interventions to address modifiable risk factors of ED utilization.

Emergency Department Utilization in the U.S. Military Health System.

INTRODUCTION: Emergency department (ED) utilization represents an expensive and growing means of accessing care for a variety of conditions. Prior studies have characterized ED utilization in the general population. We aim to identify the clinical conditions that drive ED utilization in a universally insured population and the impacts of care setting on ED use and admissions in the U.S. Military Health System. METHODS: We queried TRICARE claims data from October 1, 2012, to September 30, 2015, to identify all ED visits for adult patients (age 18-64). The primary presenting diagnoses of all ED visits and those leading to admission are presented with descriptive statistics. Logistic regression was used to identify clinical and sociodemographic factors associated with admission from the ED. RESULTS: A total of 4,687,205 ED visits were identified, of which 46% took place in the DoD healthcare facilities (direct care). The most common diagnoses across all ED visits were abdominal pain, chest pain, headache, nausea and vomiting, and urinary tract infection. A total of 270,127 (5.8%) ED visits led to inpatient admission. The most common diagnoses leading to admission were chest pain, abdominal pain, depression, conditions relating to acute psychological stress, and pneumonia. For patients presenting with 1 of the 10 most common ED diagnoses, those who were seen at a civilian ED were significantly less likely to be admitted (3.4%) compared to direct care facilities (4.1%) in an adjusted logistic regression model (Adjusted Odds Ratio 0.40 [95% CI: 0.40-0.41], P < .001). CONCLUSIONS: Ultimately, we show that abdominal pain and chest pain are the most common reasons for presentation to the ED in the Military Health System and the most common presenting diagnoses for admission from the ED. Among patients presenting with the most common ED conditions, direct care EDs were significantly more likely to admit patients than civilian facilities.

Potentially survivable fatal vascular access hemorrhage with tourniquet use: A post-mortem analysis.

BACKGROUND: The US military has prioritized battlefield hemorrhage control. Researchers credit tourniquet use, and a novel trauma care training program, with saving 1000-2000 lives in Iraq and Afghanistan. The Stop the Bleed campaign translates these lessons learned to the public. This is the first analysis of the potential impact of this newfound knowledge about tourniquet use for extremity fatal vascular access hemorrhage in a civilian population. Fatal vascular access hemorrhage includes bleeding from arteriovenous fistulas and grafts used for hemodialysis and central venous catheters. METHODS: This is a retrospective study of decedent records. We selected Maryland death records from 2002-2017 using the following search terms: "graft," "shunt," "fistula," "dialysis," and "central venous catheter." The records were analyzed for potential survivability with a checklist of military criteria modified for a civilian population. Suicides were excluded. Two reviewers independently classified the deaths as either potentially survivable or non-survivable, and a third reviewer broke ties. RESULTS: There were 111 deaths included in the final analysis. Ninety-two of the 111 decedents had potentially survivable extremity fatal vascular access hemorrhage. The remaining 19 records were excluded, because they did not have extremity hemorrhage. Zero decedents had hemorrhage deemed to be non-survivable with prompt tourniquet application. CONCLUSION: This study identified 92 Maryland extremity fatal vascular access hemorrhage decedents who potentially could have survived with tourniquet use-an average of 6 per year. These results suggest the need for further epidemiology investigation, as well as exploration of the risks and benefits of teaching and equipping vascular access patients and their caregivers to use tourniquets for life-threatening bleeding.